tbuckley/cabot-search huggingface dataset:
GD04 Patient education for all! Skin of colour ­under-represented again
Authors: Amy Long, Alison Long, Cliona Feighery
Journal: British Journal of Dermatology (2023)

Abstract Disparities in healthcare provision have a detrimental impact on health outcomes, which have been suffered by many patient cohorts, whether they are defined socially, economically or by the colour of their skin (Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin 2012; 30:53–9). In the field of dermatology, we rely hugely on visual presentations. As dermatologists, the visible manifestations of disease, and their evolution, are fundamental to how we formulate diagnoses and treatment strategies. Similarly, visual depiction is important for patients to garner a wider understanding of their condition. This study aimed to analyse skin colour representation in patient information resources for a number of inflammatory conditions, including acne, atopic dermatitis, hidradenitis suppurativa, psoriasis and rosacea. Resources from multiple dermatological bodies including the British Skin Foundation, Irish Skin Foundation, American Academy of Dermatology Association, Canadian Dermatology Association, Dermatology Society of South Africa and the Australasian College of Dermatology were reviewed. Hard-copy pamphlets published by the associations were analysed; where pamphlets were unavailable, websites pertaining to each inflammatory condition were included. Images were divided by Fitzpatrick skin type into two categories: Fitzpatrick skin types I–IV and Fitzpatrick skin types V/VI. There is no formal definition of skin of colour, and for the purposes of this study, we referred to Fitzpatrick skin types V/VI. In total, 115 images were reviewed. People with skin of colour were represented in 5% (n = 6) of the images. This stark over-representation of Fitzpatrick skin types I–IV highlights the lack of inclusivity in current patient education resources. Consequently, patients with skin of colour may feel overlooked. This may foster a poor rapport between patients and physicians and could lead to mistrust and reduced engagement with healthcare services. Dermatological communities must join the global effort to eliminate racial disparities. The first steps have already been taken by many, in publishing and medical education, including the British Journal of Dermatology, which aims to enhance resources to study, describe and improve care for people with skin of colour (Guckian J, Ingram JR, Rajan N, Linos E. Dermatology is finally talking about race. Br J Dermatol 2021; 185:875–6). Patient information resources are another facet of our practice that need focus and reform. We must improve approachability, inclusiveness and trust within our specialty and work towards the overarching aim of delivering healthcare that is racially just.
PS07 Delusional infestation: are delays in access to care adversely affecting patient outcomes? A case series
Authors: Janet Angus, Eliza Hutchison, Jo Davies
Journal: British Journal of Dermatology (2023)

Abstract Delusional infestation (DI) is the fixed, false belief of pathogenic infestation of the skin or body, despite no supporting medical evidence. Patients may be difficult to treat successfully, because of their reluctance to accept referral or involvement of psychiatric services. Research consistently supports assessment of this cohort in multidisciplinary psychodermatology clinics, where integrated medical and psychiatric care can be seamlessly provided. The British Association of Dermatologists (BAD) All Parliamentary Group has recommended increased psychodermatology services across the UK, but provision is still scanty. We report a review of 49 consecutive patients (12 men and 37 women) with a diagnosis of DI assessed in a regional psychodermatology service. Mean patient age was 63 years (range 41–92). Mean duration of symptoms before attending was 4.9 years. Forty-one (84%) patients complained of living creatures, with the other eight (16%) perceiving fibres or other inanimate objects. Perception of nonliving mater­ial was strongly associated with substance misuse. Low-dose antipsychotics were prescribed in 44 (90%) patients. Risperidone (n = 39; 89%) and olanzapine (n = 5; 11%) were the drugs prescribed. Medications were well tolerated, with no significant adverse side-effects reported. Twenty-three (47%) responded to treatment. Four patients developed full-blown psychotic disorders. We were unable to engage 13 (27%) patients in treatment, and in three (6%), the treatment outcomes were unknown. Responders had a mean time to presentation of 3.7 years vs. nonresponders who had symptoms for an average of 5.9 years. Ten (20%) patients admitted to current or previous substance misuse. Twenty-one (43%) had a history of psychiatric disease. Substance misuse and established psychiatric disorders were associated with poorer engagement and response. Response to treatment and engagement with services is multifactorial. This review demonstrated that delays in presentation are associated with poorer outcomes (Romanov DV, Lepping P, Bewley A et al. Longer duration of untreated psychosis is associated with poorer outcomes for patients with delusional infestation. Acta Derm Venereol 2018; 98:848–54). In 2016, early intervention in psychosis services was introduced as a National Institute for Health and Care Excellence standard in the UK. In psychiatry, there is well-established evidence of the relationship between delays in treatment of psychosis and poorer outcomes. The BAD guidelines have recently been published to encourage more widespread prescribing of low-dose antipsychotics to expedite treatment. Our review highlights that all patients with DI face significant delays to treatment, which may adversely impact or increase the complexity of clinical presentations. This review emphasizes the importance of early assessment and supports the expansion of psychodermatology services.
BI01 Disseminated <i>Nannizziopsis</i> fungal infection in a kidney transplant recipient: iguanas, immunosuppression or international travel?
Authors: Jeva Cernova, Salma Haddad, Portia Goldsmith, Diana Mabayoje, Jonathan Lambourne, Mark Melzer, Yaqoob Magdi, Conor Byrne, Catherine Harwood
Journal: British Journal of Dermatology (2023)

Abstract Transplant waiting list demographics are changing profoundly in some parts of the UK, partly due to trends in global migration. This has significant implications for the spectrum of post-transplant skin malignancies and skin infections presenting to dermatologists. We present a kidney transplant recipient born in Nigeria who developed disseminated infection with Nannizziopsis spp., an emerging pathogenic fungus in humans and reptiles. A 64-year-old man from Nigeria who received a kidney transplant 10 months earlier was referred to our 2-week-wait skin cancer clinic with a 4-cm tender, ulcerated nodule on his left thigh that had been present for 2 months. He was being investigated for possible pulmonary Aspergillus infection and also had a fluctuant subcutaneous mass over the right tibia with suspected osteomyelitis. On examination, he had a similar plaque on his right hand, fluctuant subcutaneous nodules of his left flank and left upper arm, a 20-cm fluctuant swelling over his right tibia and a 2-cm plaque of his hard palate. Skin biopsy from the left flank and thigh showed suppurative granulomatous inflammation and fungal hyphae in the dermis and macrophages with septation and 45° branching. β-D-Glucan was positive and molecular identification revealed Nannizziopsis spp. Magnetic resonance imaging of the head did not show evidence of central nervous system infection. He was treated with intravenous amphotericin B for 2 months and subsequent oral posaconazole with resolution of skin and lung infection. Nannizziopsis is a genus of fungi that usually infects reptiles such as iguanas, geckos and chameleons, snakes, turtles and crocodiles. It causes cutaneous and musculoskeletal granulomatous infections which can be rapidly fatal. Fewer than 20 human cases have been reported, mostly related to travel to West Africa. Almost all infections are in immunocompromised individuals and species of Nannizziopsis reported to affect humans are generally different from those identified in animals. Our patient denied contact with reptiles, but he had travelled to Nigeria before his transplant where he probably acquired a latent infection that reactivated post-transplant. This case illustrates the importance of biopsy and culture of atypical skin lesions, particularly in immunocompromised patients. With the rising global migration and travel, such infections are likely to be seen more frequently in the UK, and both residential and travel history may be relevant. Finally, zoonotic infections are increasing globally as interspecies barriers break down. Although there is not enough evidence to caution against ownership of exotic pets in immunocompromised individuals, animal sources of rare infections should always be considered in this patient group.
DP10 A relapsing–remitting rash with associated neurological symptoms: a rare presentation of ​­neuro-Sweet syndrome
Authors: Prachi Desai, Lianne Thomas, Vrinda Bajaj
Journal: British Journal of Dermatology (2023)

Abstract A 46-year-old woman presented with an 8-week history of an asymptomatic eruption on her upper extremities and back. She had a history of ulcerative colitis, asthma and hyposplenism. There had been no changes to her regular medications. Over the next 3 years, she developed a relapsing and remitting course of headaches, pyrexia and feeling unwell with the associated rash. She further developed deafness and vertigo and was admitted with headaches, blurred vision and paraesthesia of the fingers. Physical examination revealed multiple erythematous, asymptomatic, annular plaques present on her upper extremities and back with no oral, genital or ophthalmological lesions. Skin biopsy from the lesion on the upper back showed a neutrophilic dermatosis with mildly acanthotic epidermis, superficial dermal collection of acute inflammatory cells, dermal oedema and endothelial swelling, with no evidence of vasculitis. This was considered in keeping with Sweet syndrome. Magnetic resonance imaging of the brain revealed meningoencephalitis and focal cerebritis. A lumbar puncture performed for infection was negative. Following this, a diagnosis of neuro-Sweet syndrome (NSS) was made. She has responded well to oral steroids and is currently well controlled on dapsone. To date, extensive malignancy screens have been negative. Sweet syndrome, or acute febrile neutrophilic dermatosis, is characterized by fever, malaise, leucocytosis and painful distinctive skin lesions and may be associated with malignancies, drugs and infection. Skin biopsy shows dense dermal infiltration of neutrophils without any histological signs of vasculitis. Sweet syndrome is known to involve multiple organs; however, involvement of the central nervous system (CNS) is rare. When the CNS is involved, it is referred to as NSS and is defined as the coexistence of characteristic skin lesions of Sweet syndrome with encephalitis or meningitis (Suh HB, Kim HJ. Recurrent neuro-Sweet disease associated with preceding upper respiratory infection: a case study. iMRI 2018; 22:187–93). Although the condition is usually steroid responsive, disease recurrences have been reported in 50% of cases in the literature (Hisanaga K, Iwasaki Y, Itoyama Y, Neuro-Sweet Study Group. Neuro-Sweet disease: clinical manifestations and criteria for diagnosis. Neurology 2005; 64:1756–61). It is important to note that the clinical features and imaging results in NSS are similar to those of neuro-Behçet disease (NBD), and it is important to distinguish between the two as CNS involvement in NSS is often transient, whereas NBD often follows a more progressive course. We report a rare case of NSS and highlight that NSS should be considered by dermatologists in patients presenting with recurrent skin lesions of Sweet syndrome and associated neurological symptoms.
DS17 Postoperative wound complications following dermatological surgery: an audit leading to improved clinical practice, patient outcomes and informed consent
Authors: Jake Kennedy, Aparna Potluru, Maria Farled, Ruth Jones, Shantini Rice
Journal: British Journal of Dermatology (2023)

Abstract In 2021, an apparent spike in wound complications presenting to our dressings clinic prompted a prospective audit of complications following dermatological surgery. The aim was to quantify the rate of and identify risk factors leading to postdermatological surgery complications for clinical governance and to improve clinical practice and patient outcomes. Secondary outcomes were to provide operators with individual annual complication rates. A further outcome pertinent to the Montgomery ruling was to use the data to refine preoperative patient information with precise detail on risk prior to surgery. Patients undergoing a dermatological surgery procedure between 1 April 2021 and 31 December 2022 across three hospital sites were included in this audit. Prospective data were collected via a departmental surgical complications proforma, supplemented by collating retrospective data from nurse-led wound review clinics via our electronic patient record system. Data were gathered on patient age and sex; operator grade; presenting problem (pain/dehiscence/infection/bleeding/other); surgical site; route of referral; microbacterial swab, cultured organism, antibiotic prescribing; anticoagulation; type of procedure; suture type; days to suture removal; and provision of pre- and postoperative patient information on skin surgery. Over a 21-month period &amp;gt; 11 000 procedures were performed, with a median of 574 procedures per month. In total, 256 patients reported 331 complications: 124 were suspected infections (37.5%); 63 were reports of pain (19.0%), 62 of bleeding (18.7%) and 52 of dehiscence (15.7%); and 30 (9.1%) were other complications such as graft failure. Surprisingly, the majority of complications (41%) occurred on the head and neck. Of patients presenting with bleeding, most were not taking prescribed anticoagulants. Seventy-two per cent of positive swabs grew Staphylococcus aureus. In 2019, the British Association of Dermatologists (BAD) performed a national audit of process, based on measures of quality in a dermatology skin surgery service. Sixty-four per cent of 201 respondents from the BAD and British Association of Dermatological Surgery reported no formal mechanism for determining wound complications following skin surgery (https://cdn.bad.org.uk/uploads/2022/02/29200022/Skin-Surgery-National-Audit-Report-2019.pdf). In our experience, using a departmental proforma has enabled quantification of departmental postoperative complication rates against anatomical site, procedure, patient factors and level of operator, improving clinical practice, governance, informed consent and patient outcomes. It is hoped that our work might usefully contribute to the development of a national proforma for collating data on wound complications, which has wider implications for maintaining high standards of dermatological surgery practice across the UK.
PS11 Dupilumab for moderate-to-severe atopic dermatitis: transformative changes in quality of life and low burden of treatment — a mixed-methods study
Authors: Emma Porter, Cathal O’Connor, Michelle Murphy
Journal: British Journal of Dermatology (2023)

Abstract Moderate-to-severe atopic dermatitis (AD) has a significant impact on quality of life (QoL). The emergence of biologic agents has changed the treatment landscape for those with severe disease. Adult patients on biologic treatment for moderate-to-severe AD were invited to complete written questionnaires during scheduled clinical care. Questionnaires prompted reflection on QoL before and after treatment with dupilumab. Dermatology Life Quality Index (DLQI) and Burden of Treatment (BoT) scores were simultaneously assessed. Charts were retrospectively reviewed with respect to prior treatments, duration of biologic treatment, adverse events and clinical severity scoring. Statements were assessed qualitatively to identify common themes. Twenty-one patients participated in the study. The median age of participants was 38 years. Most (n = 14; 67%) were men. All patients were on subcutaneous dupilumab 300 mg, for a median duration of 10 months (range 3–61). Thirteen patients had trialled one immunosuppressant agent prior to commencing dupilumab, and five had failed two or more agents. Three had contraindications to immunosuppression. Median DLQI prior to commencing biologic treatment was 22 (range 9–30, SD 5.5), improving to 2 (range 0–11, SD 3.1) at the time of study participation. Median Eczema Area and Severity Index scores were 30.2 before dupilumab and 6.4 at the time of participation. Median BoT scores on dupilumab were low (range 0–3/10) across all domains, including burden related to emollients, topical steroids, injections, cost and scheduling of appointments. Themes identified in patients’ descriptions of prebiologics QoL included embarrassment, low self-esteem, anxiety, poor quality of social relationships, sleep disturbance, perceived loss of autonomy, loss of time, frustration with health services, high financial costs, negative childhood memories and hopelessness about the future. All patients described dramatic improvements on dupilumab. Themes included the disappearance of itch, confidence reacquisition, improved relationships, the ability to sleep, enjoyment of activities, freedom of clothing choice, greater free time, improved daily functioning, liberation from topical steroids and reclaiming control. Three patients (14%) reported disappointment with incomplete clearance, all relating to persisting facial dermatitis. Six patients (29%) reported side-effects on dupilumab, all described as mild eye symptoms, which did not affect QoL. This study highlights the profound impact of dupilumab therapy for moderate-to-severe AD on physical, psychological and social functioning. The transformative life changes described by patients on biologic treatment are compelling. Side-effects described were minor and more tolerable than with conventional immunomodulatory treatments, with a low burden of treatment in all patients.
BI19 Cutaneous post-transplant lymphoproliferative disorder in an immunosuppressed patient
Authors: Evangelia Vetsiou, Steve Smith, Vanessa Van-de-Velde
Journal: British Journal of Dermatology (2023)

Abstract Post-transplant lymphoproliferative disorders (PTLDs) are a common form of de novo neoplasia developing in patients with immunosuppression following a transplant. The majority are associated with Epstein–Barr virus (EBV) infection. Cutaneous PTLD manifestations are rare and not well documented in literature. We present a case of systemic PTLD with secondary extensive cutaneous involvement 4 months after allogenic stem cell transplant for JAK2-mutated myelofibrosis. A 68-year-old man was admitted to the haematology department with fevers, diarrhoea, cytopenia, EBV viraemia and a nodular rash behind his ears. Biopsies from colonoscopy confirmed monomorphic PTLD with subsequent extensive ileocalceal lymphadenopathy area detected on computed tomography. Asymptomatic, large, hardened violaceous nodules on the head and neck worsened further. Skin biopsy showed an infiltrate of atypical lymphocytes in the dermis, composed predominantly of large lymphoid cells with visible prominent nucleoli. A limited immunohistochemical panel showed positivity for BCL-2 but not CD20. EBV-encoded RNA in situ hybridization was also positive. Features were compatible with cutaneous involvement by the known monomorphic PTLD. Unfortunately, the patient deteriorated with haemodynamic instability due to sepsis, despite two further infusions of rituximab, and was directed to the palliative team. He died soon after the discontinuation of all treatments. PTLD has a wide spectrum of clinical manifestations. It is classified into three nondestructive types: polymorphic, monomorphic and classic Hodgkin lymphoma type. It can have a poor prognosis so it should always be considered as a diagnosis in transplant patients. Monomorphic PTLDs tend to be more aggressive and rarely respond to immunosuppression reduction. On the contrary, primary cutaneous involvement is rare and seems to have a favourable outcome. Treatment depends on the severity of the disease, and both localized and systemic therapies have been used. Transplant patients should have long-term follow-up to diagnose and promptly treat possible complications.
BG12 A case of severe gastrointestinal bleeding while on vismodegib therapy
Authors: Hamisha Salih, Sarah Ryan, Anna Ascott, Claudia DeGiovanni
Journal: British Journal of Dermatology (2023)

Abstract We report the case of a 50-year-old woman, with a history of Gorlin syndrome on vismodegib therapy, who presented with two episodes of upper gastrointestinal bleeding (UGIB) in the absence of other risk factors. Gorlin syndrome is a rare disorder characterized by multiple basal cell carcinomas (BCCs) secondary to a mutation in PTCH1. Mutations in PTCH1 lead to dysregulation of the hedgehog signalling pathway and subsequent abnormal proliferation. Vismodegib is a systemic hedgehog inhibitor that has been shown to be effective in treating advanced BCCs and Gorlin syndrome. Our patient acquired multiple BCCs which excision, photodynamic therapy and topical chemotherapy agents failed to control. Therefore, a decision to commence vismodegib was made. During treatment with vismodegib, she had a perforated gastrointestinal ulcer and required an emergency laparotomy. Vismodegib was stopped, but over the next few years, her BCCs progressed again to an excess of 50 BCCs, including large plaques of carcinoma measuring up to 12 cm in diameter. Vismodegib was restarted with a high-dose proton–pump inhibitor cover, as recommended by the gastroenterology team, and her BCCs were largely resolved. However, a second bleed occurred approximately 1 year after restarting treatment. Gastroscopies undertaken following these episodes were largely normal, showing mild, nonerosive duodenitis only, and Helicobacter pylori testing was negative. Given the lack of pre-existing risk factors and temporal relation to vismodegib therapy, the decision was made to suspend the drug. To our knowledge, this is the first case reported in the literature of UGIB associated with vismodegib. A separate case has reported colonic mucosal changes in a patient with chronic diarrhoea on vismodegib. The hedgehog protein and RNA expression have been found to be present in the gastrointestinal endothelium and mesenchyme. Evidence suggests the hedgehog pathway activation in gastrointestinal lining is involved in the wound-healing response, endothelial turnover and activation of mesenchymal immune responses. Therefore, inhibition of the hedgehog pathway via vismodegib could potentially impair the essential maintenance of the gastrointestinal endothelium. We postulate that this mechanism could have led to the presentation in our patient, through endothelial damage exposure of vessels leading to gastrointestinal bleeding. Treatment options for BCC in our patient are now limited. Vismodegib is one of the few therapies that has been shown to induce remission of symptoms and reduce disease burden. We present this case to raise awareness of this potential adverse event.